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Medicare reimburses Medicare Advantage plans using a complex formula called a risk score that computes higher rates for sicker patients and lower ones for healthier people - but federal officials rarely demand documentation to verify that patients have these conditions.

A review of 90 government audits reveals that health insurers that issue Medicare Advantage plans have repeatedly tried to sidestep regulations requiring them to document medical conditions the government paid them to treat. Read more»

CMS has completed only 90 audits over the past decade, a time when Medicare Advantage has grown explosively.

Newly released federal audits reveal widespread overcharges and other errors in payments to Medicare Advantage health plans for seniors, with some plans overbilling the government more than $1,000 per patient a year on average. Read more»

Private equity has tended to find legal ways to bill more for medical services: trimming services that don’t turn a profit, cutting staff, or employing personnel with less training to perform skilled jobs.

Private equity is rapidly moving to reshape health care in America - coming off a banner year in 2021 when the deep-pocketed firms plowed $206 billion into more than 1,400 acquisitions - and evidence is mounting that the practice has led to higher prices and diminished quality of care. Read more»

Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year, government watchdogs told a House panel. Read more»

After paying more than $9,000 in premiums and fees over 13 months to O’NA HealthCare, Jill Goodridge says, she could not get O’NA to cover her family’s medical bills. Frustrated, the Rockland, Maine, resident complained to state regulators in summer 2018. “It almost seemed like we were just spending the premium money every month for really not much,” she says.

O'NA HealthCare claimed Native American tribal affiliation to entice customers and avoid federal oversight. Read more»

The Justice Department has joined a California whistleblower’s lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans. Read more»

Medicare pays the privately run health plans — an alternative to traditional Medicare — a set monthly rate for each patient. About 16 million Americans have signed up at an annual cost to taxpayers of more than $160 billion, about one third of the elderly and disabled people eligible for Medicare. A Center for Public Integrity investigation published in June found as much as $70 billion of improper payments to Medicare Advantage plans from 2008 through last year. Read more»

Critics warned of billing abuse in Medicare Advantage health plans, but oversight is lagging. Read more»

Q & A with Center for Public Integrity reporter Fred Schulte. Read more»

Josh Valdez, former health official under George W. Bush.

Company says former Bush health official simply a "disgruntled employee." Read more»

Humana Inc. faces multiple federal investigations into allegations that it overbilled the government for treating elderly patients enrolled in its Medicare Advantage plans, court records reveal. Read more»

Center analysis and American Hospital Association

Federal officials for more than a decade have let hospitals decide on their own how much to charge Medicare for certain emergency room overhead and staffing costs called “facility” fees — a controversial policy some critics believe invites overcharges. Now in a major turnabout, the Centers for Medicare and Medicaid Services are seeking tighter controls over the fees as part of a plan to redirect billions of dollars Medicare spends annually on outpatient health care. Read more»

The Department of Health and Human Services headquarters by the National Mall.

Citing massive budget and staff cuts, federal officials are set to scale back or drop a host of investigations into Medicare and Medicaid fraud and abuse — even though cracking down on government waste and cutting health care costs have been top priorities for the Obama administration. Read more»

Farzad Mostashari, MD, National Coordinator

The Obama administration is forging ahead with a multi-billion dollar plan to shift from paper to electronic medical records, despite continuing concerns the program may be prompting some doctors and hospitals to improperly bill higher fees to Medicare. Read more»

The agency's crippled oversight of the industry means troubled gun dealers can stay open for years. Some don’t see an inspector for eight years or more. By law, ATF can inspect dealers once a year only and may revoke a license only when it believes the dealer “willfully” violated gun control laws. Read more»

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